CONTRIBUTION Driving Policy after Seizures and Unexplained Syncope: A Practice Guide for RI Physicians MAXWELL E. AFARI, MD; ANDREW S. BLUM, MD, PHD; STEPHEN T. MERNOFF, MD; BRIAN R. OTT, MD 40 43 EN ABSTRACT chose from six possible driving restriction durations: No Physicians in Rhode Island sometimes find it difficult restriction, 3 months, 6 months, 12 months, 18 months, to advise patients about returning to driving after they other (with explanation). The questions asked are presented present with a seizure or syncopal episode due to lack in Table 1. of statutory or professional guidance on the issue. We provide an overview of the medical literature on public policies and recommendations regarding driving after RESULTS seizures or syncope. We also present the laws in Rhode According to RINS/RINA/AAN records there are approxi- Island regarding physician notification of the medical ad- mately 60 practicing neurologists in RI, and most of them visory board of the Department of Motor Vehicles, legal were contacted to complete the survey. Thirty neurologists, obligations, and immunity from prosecution for those representing approximately 50% of practicing neurologists who report. Finally, we present the results of a survey of in Rhode Island, responded to the survey. As demonstrated current practice by Rhode Island neurologists when they in Table 2, in the setting of a first seizure with loss of con- advise patients who have had a recent seizure or unex- sciousness, more than half of the respondents recommended plained syncopal event. Based upon this information, we a 6-month driving restriction irrespective of an identified hope local practitioners are empowered in their decision seizure focus (70.0 %) or normal EEG and MRI (63.3%). Sur- making on driving restrictions and we hope this data prisingly, half (50.0%) of the surveyed neurologists were in informs future public policy efforts. favor of 6 months driving restrictions even with seizure pre- KEYWORDS: driving recommendations, seizures, sentations without loss of body control. unexplained syncope Respondents showed consensus when questioned about patients with nocturnal seizures. Eighteen neurologists rep- resenting 60% of respondents were in favor of a 6-month driving restriction; 16.7% (5) respondents chose “Other” and some of the explanations given included: “It depends INTRODUCTION how well established the nocturnal seizure pattern is;” “Do Many physicians find it difficult to prescribe driving rec- not drive at night;” and “If not first ever event and well ommendations to patients who present with seizure or un- documented only at night, would not restrict.” explained syncope. Some of the questions that arise include: How long should drivers stay off the road? After prescribing Table 1. Online survey questions posed to neurologists in Rhode Island. restrictions, are physicians obliged to report this to state au- EEG: Electroencephalography, MRI: Magnetic resonance imaging thorities? And if a physician chooses to notify the authori- How would you advise a patient who: ties, is the physician immune from prosecution for breaking confidentiality? The last review article on driving policies Presents with a first seizure (complex partial or with loss of and physicians relevant to Rhode Island was published over consciousness) but has a normal EEG and MRI? a decade ago.1 The current article provides an update to this Presents with first seizure (complex partial or with loss of review and reports the first survey of neurologists on their consciousness) and has an identified seizure focus? current driving-related practices in our state. Presents with first partial seizure that does not affect awareness or bodily control? METHODS Presents with only nocturnal seizures? Academic neurologists and members of the Rhode Island Is suspected of having psychogenic or non-epileptic seizures with Neurological Society (RINS) and Rhode Island Neurology loss of consciousness or bodily control? Association (RINA) were invited to participate in an on- Presents with unexplained syncopal episode with normal EEG line survey about driving recommendations post syncope and cardiac monitor? or seizure. Different scenarios were created and physicians WWW.RIMED.ORG | RIMJ ARCHIVES | JANUARY WEBPAGE JANUARY 2014 RHODE ISLAND MEDICAL JOURNAL 40 CONTRIBUTION For non-epileptic (“psycho- Table 2: Recommended duration of driving restrictions after syncope or seizure by neurologists in the state of genic”) seizures the recom- Rhode Island. mendations were equivocal LOC: loss of consciousness, EEG: Electroencephalography, MRI: Magnetic resonance imaging (Table 2). Close to half of Driving restrictions (Months) respondents advise a 6-month Seizure/Syncope driving restriction (n=13, (% respondents) 0 3 6 12 18 Other 43.3%) while one-fifth (20%) Seizure LOC/Normal EEG-MRI (n) % (2) 6.7 5 (16.7) (19) 63.3 (1) 3.3 (0) 0.0 (3) 10.0 recommended a 3-month seizure-free period. Neurol- Seizure LOC/ Identified Focus (n) % (0) 0.0 (2) 6.7 (21) 70.0 (4) 13.3 (2) 6.7 (1) 3.3 ogists who selected “Other” Seizure/ Body Control (n) % (5) 16.7 (4) 13.3 (15) 50 (2) 6.7 (0) 0.0 (4) 13.3 explained: “It depends on the confidence in non-epileptic Nocturnal Seizures (n) % (2) 6.7 (2) 6.7 (18) 60.0 (3) 10.0 0 (0.0) (5) 16.7 diagnosis;” “It depends on the Psychogenic/ Non-Epileptic (n) % (3) 10.0 (6) 20.0 (13) 43.3 (2) 6.7 (1) 3.3 (5) 16.7 suspicion for real seizures.” The recommendations for Unexplained Syncope (n) % (8) 26.7 (5) 16.7 (8) 26.7 (0) 0.0 (0) 0.0 (9) 30 “unexplained syncope” were very varied. As shown in Table 2, 26.7% did not think a driving restriction was war- the findings of our survey are highly relevant to informing ranted while another 26.7% advocated for a 6-month sei- decision making on driving restrictions. The majority of the zure-free period. The variability in opinion was reflected by neurologists in Rhode Island would restrict patients from the observation that 30% of respondents chose “Other” and driving for a 6-month period for any kind of seizure that provided varying detailed explanations, including: “Patient involves loss of consciousness and/or loss of motor control needs cardiology evaluation;” “Medical advice is to avoid adequate for driving. driving if episodes recur but no legal restriction on driving if living in RI;” “I will ask them to consult with their PCP, National guidelines otherwise 6 months;” and, “Syncope is not common while How do these practices square with published guidelines sitting so would watch for a while.” from national medical associations? Two decades ago the American Academy of Neurology (AAN), American Epilep- Epilepsy and Driving Restrictions sy Society (AES) and the Epilepsy Foundation of America Epilepsy refers to recurrent seizures which causes altered (EFA) in a consensus statement advocated for a more liberal neurological function. States have varying driving restric- 3-month seizure-free period.6 However, in their landmark tions in terms of seizure-free periods, varying between 3 consensus paper they noted that factors such as: structural and 12 months.2 The optimal seizure-free period is still un- brain disease, uncorrectable brain functional or metabolic known. In a study by Krauss et al, longer seizure-free inter- disorder, frequent seizure recurrence after seizure-free in- vals, i.e. ≥6-12months, significantly reduced seizure-related tervals and prior crashes caused by seizures could lengthen motor vehicle accidents compared to shorter seizure-free the duration. Favorable modifiers included seizures that do periods.3 A three-month seizure-free period compared to not interfere with consciousness or motor function, seizures shorter ones demonstrated greater odds in reducing sei- with consistent and prolonged auras, established pattern of zure-related MVAs; however, no statistical significance was pure nocturnal seizures, and seizures related to metabolic seen. By comparison, in Arizona a 12-month seizure-free pe- states or illness that are unlikely to recur. riod failed to significantly reduce seizure-related car crashes Overall it appears that the scientific evidence supports and deaths compared to a 3-month criterion.4 driving restrictions of 3-12 months duration, but not 18 The privilege to drive is regulated by the state division months. However, it is very important that physicians use of motor vehicles (DMV). In neighboring Massachusetts, their clinical judgment in prescribing driving restrictions. the recommendation is for a 6-month seizure-free period. The 30-year-old woman with a first idiopathic unprovoked In Rhode Island there are no regulations or state-published seizure could be restricted from driving for 3 months, and advisories regarding seizure-free periods. The Epilepsy Foun- this would be consistent with the recommendations of dation of America’s website references 18 months5 for Rhode the Canadian Medical Association.7 The middle-aged man Island, which seems to have been an unpublished recom- with structural brain disease on anti-epileptic medication mendation for Rhode Island in the past. At some point more presenting with recurrent tonic-clonic seizures while driv- than 20 years ago, Rhode Island switched from this uniform ing would most likely require greater restriction such as 6 18-month recommendation to a more flexible recommen- months or longer. dation from the Medical Advisory Board (MAB) that deter- It must be noted that commercial drivers who use in- mines driving restrictions on a case-by-case basis.2 In light terstate roads present a different situation for advisement. of this lack of clearly defined public policy in Rhode Island, These categories of drivers are governed by the Federal WWW.RIMED.ORG | RIMJ ARCHIVES | JANUARY WEBPAGE JANUARY 2014 RHODE ISLAND MEDICAL JOURNAL 41 CONTRIBUTION Department of Transportation (DOT), whose regulations and editorials on the subject.12,14 For unexplained syncope, bar people with history of seizure or epilepsy from driving many (including 26.7% of our surveyed neurologists) would in interstate commerce at all, unless they have been off suggest no restriction, unless there is absence of a prodromal seizure medication and seizure free for 10 years.